BAC Modification through Serial or Simultaneous Use of CRE/Lox Technology

Bacterial Artificial Chromosomes (BACs) are vital tools in mouse genomic analyses because of their ability to propagate large inserts. The size of these constructs, however, prevents the use of conventional molecular biology techniques for modification and manipulation. Techniques such as recombineering and Cre/Lox methodologies have thus become heavily relied upon for such purposes. In this work, we investigate the applicability of Lox variant sites for serial and/or simultaneous manipulations of BACs. We show that Lox spacer mutants are very specific, and inverted repeat variants reduce Lox reaction rates through reducing the affinity of Cre for the site, while retaining some functionality. Employing these methods, we produced serial modifications encompassing four independent changes which generated a mouse HoxB BAC with fluorescent reporter proteins inserted into four adjacent Hox genes. We also generated specific, simultaneous deletions using combinations of spacer variants and inverted repeat variants. These techniques will facilitate BAC manipulations and open a new repertoire of methods for BAC and genome manipulation

LOW SERUM SODIUM LEVELS AT HOSPITAL ADMISSION: OUTCOMES AMONG 2.3 MILLION HOSPITALIZED PATIENTS

Background: Hyponatremia is the most common electrolyte disorder among hospitalized patients. Controversies still exist over the relationship between hyponatremia and outcomes of hospitalized patients. Methods: To analyze the association of low serum sodium levels at hospital admission with in-hospital mortality and patient disposition and to compare the distribution of the risk of death associated with hyponatremia across the lifespan of hospitalized patients, we conducted an observational study of 2.3 million patients using data extracted from the Cerner Health Facts database between 2000 and 2014. Logistic regression models were used in the analyses. Results: 14.4% of hospitalized patients had serum sodium levels [Na]/L. In adjusted multinomial logistic regression analysis, we found that the risk of in-hospital mortality significantly increases for [Na] levels \u3c 135 or ≥143 to ≤145 mEq/L compared to the reference interval of 140 toConclusions:Hyponatremia is common among hospitalized patients and is independently associated with in-hospital mortality, discharge to hospice or to a nursing facility. The risk of death and other outcomes was more evident for [Na]/L. The mortality associated with low [Na] was significantly higher in younger versus older patients

A Kidney Biopsy Simulation Training Program: First Year\u27s Results

BACKGROUND: Nephrology attracts fewer medical graduates despite the growing care and workforce demand. Interventional Nephrology could re-foster interest in this subspecialty. Percutaneous kidney biopsy (PKB) is the most common procedure and should be adequately taught through simulation training according to ACGME requirements. We initiated a PKB simulation training program and we designed a two-year study in order to examine its effect on the confidence level, the procedural competence and the satisfaction with this training of Nephrology fellows compared to historical controls (fellows trained on PKBs before the initiation of the program). METHODS: All fellows were consented and trained at UNM’s simulation center (BATCAVE) with a renal biopsy ultrasound training model (CAE Healthcare Blue PhantomTM). Participants demographics and previous PKB experience was collected. Pre-assigned readings, online videos and hands-on practice on the simulation model were utilized as educational strategies. Performance of the trainee during each one-hour session was graded by the use of an evaluation form specifically designed for PKBs. Pre-and post-simulation surveys evaluated the participants’ confidence level quantitatively. All participants completed the satisfaction with PKB simulation experience scale (PKB-SSE). RESULTS: All three 1st and 2nd year current renal fellows completed the simulation training. The following table summarizes the basic information acquired from their training. Overall, the program enhanced the confidence level of fellows without previous experience on performing PKBs. All fellows expressed a high level of satisfaction from their participation in this training. CONCLUSIONS: PKB simulation training may improve trainees’ confidence level especially for those without prior experience as well as their satisfaction with the training. The procedural competence of the trainees on PKBs will be evaluated during the second year of their fellowship and will be compared to the procedural competence of historical controls

Time and Financial Costs for Students Participating in the National Residency Matching Program (the Match©): 2015 to 2020

Introduction. The purpose of this study was to provide information to assist students, faculty, and staff in making critical career-determining decisions regarding the residency NRMP “Match©” process. Methods. A 47-item survey questionnaire was developed and piloted on a regional medical school campus in 2015. The revised questionnaire was distributed each year from 2016 to 2020 to fourth-year medical students after rank lists had been submitted. The questionnaire incorporated a request for comments about the interviewing experience and suggestions to improve the process. This narrative feedback was coded using a thematic analysis. Results. The overall response rate was 86.1% (897/1,042). Annual response rates ranged from 70.0% in 2020 to 97.0% in 2018. Respondents’ average age was 27.3 (± 2.7) years and 50.0% (448/897) were male. Most applied to family medicine (164/897; 18.2%) and internal medicine (140/897; 15.6%). Eight specialties had fewer than ten applicants over the six-year period. The number of students applying to individual specialties fluctuated annually, but no specialty showed a consistent upward or downward trend over the study period. Conclusions. This study found huge differences in numbers of applications, expenses, and days interviewing. Students crave more guidance, a more efficient system, transparent communication with programs, and less pressure during the process. Reducing escalating volumes of applications is central to improving the system. Despite efforts to inform applicants better, student behavior is unlikely to change until they feel safe in the belief that lower and more realistic numbers of applications and interviews are likely to result in securing an appropriate residency position

A Kidney Biopsy Simulation Training Program for Renal Fellows: Two Years of Results

Renal interventions could re-foster interest in Nephrology and attract more medical graduates. Percutaneous kidney biopsy (PKB) is an important diagnostic tool and should be taught through simulation. We initiated a PKB simulation training program and designed a 2-year study to examine its effect on the confidence level, the procedural competence and the satisfaction with this training of Nephrology fellows compared to historical controls. All fellows were consented and trained at UNM’s simulation center (BATCAVE) with a simulation training model (CAE Healthcare Blue PhantomTM). Trainees’ demographics and previous PKB experience were collected. We utilized pre-assigned readings, online videos and hands-on simulation practice. Performance of each trainee during each session was graded with a procedural competence evaluation form. Drs. JO and MER were present in all sessions and completed these forms. Each session lasted 1 to 1-1 1/2 h. Pre-and post-simulation surveys evaluated the participants’ confidence level quantitatively on a 5-point Likert scale. All participants completed the satisfaction with PKB simulation experience scale (PKB-SSE). All three 1st and 2nd year renal fellows completed the simulation training in 2018 and two first year fellows completed the training in 2019. Independent of their previous experience on PKBs all renal fellows expressed a high level of satisfaction from their participation (4 to 5) and increased their confidence level. This year’s trainees increased their performance level from 2 to 5 and from 1 to 5, respectively. PKB simulation may improve trainees’ confidence level and their satisfaction with the training. The procedural competence of the trainees on PKBs will be evaluated during the 2nd year of their fellowship and will be compared to the procedural competence of historical controls. We expect that the simulation training will reduce the discomfort and minimize the adverse PKB outcomes in patients undergoing PKB in UNMH

Infrequent dialysis: a new paradigm for hemodialysis initiation.

Nearly a half-century ago, the thrice-weekly hemodialysis schedule was empirically established as a means to provide an adequate dialysis dose while also treating the greatest number of end-stage renal disease (ESRD) patients using limited resources. Landmark trials of hemodialysis adequacy have historically been anchored to thrice-weekly regimens, but a recent randomized controlled trial demonstrated that frequent hemodialysis (six times per week) confers cardiovascular and survival benefits. Based on these collective data and experience, clinical practice guidelines advise against a less than thrice-weekly treatment schedule in patients without residual renal function, yet provide limited guidance on the optimal treatment frequency when substantial native kidney function is present. Thus, during the transition from Stage 5 chronic kidney disease to ESRD, the current paradigm is to initiate hemodialysis on a "full-dose" thrice-weekly regimen even among patients with substantial residual renal function. However, emerging data suggest that frequent hemodialysis accelerates residual renal function decline, and infrequent regimens may provide better preservation of native kidney function. Given the high mortality rates during the first 6 months of hemodialysis and the survival benefits of preserved native kidney function, initiation with twice-weekly treatment schedules ("infrequent hemodialysis") with an incremental increase in frequency over time may provide an opportunity to optimize patient survival. This review outlines the clinical benefits of post-hemodialysis residual renal function, studies of twice-weekly treatment regimens, and the potential risks and benefits of infrequent hemodialysis

Usage of query-based health information exchange after event notifications

ABSTRACT Objectives: This study sought to quantify the association between event notifications and subsequent querybased health information exchange (HIE) use among end users of three different community health information organizations. Materials and Methods: Using system-log data merged with user characteristics, regression-adjusted estimates were used to describe the association between event notifications and subsequent query-based HIE usage. Results: Approximately 5% of event notifications were associated with query-based HIE usage within 30 days. In adjusted models, odds of query-based HIE usage following an event notification were higher for older patients and for alerts triggered by a discharge event. Query-based HIE usage was more common among specialty clinics and Federally Qualified Health Centers than primary care organizations. Discussion and Conclusion: In this novel combination of data, 1 in 20 event notifications resulted in subsequent query-based HIE usage. Results from this study suggest that event notifications and query-based HIE can be applied together to address clinical and population health use cases

Characterizing pre-dialysis care in the era of eGFR reporting: a cohort study

<p>Abstract</p> <p>Background</p> <p>Chronic kidney disease (CKD) is a common disorder associated with increased morbidity and mortality. Primary care physicians (PCPs) care for the majority of pre-dialysis CKD patients; however, PCPs often do not recognize the presence of CKD based on serum creatinine levels. Prior studies suggest that PCPs and nephrologists deliver suboptimal CKD care. One strategy to improve disease awareness and treatment is estimated glomerular filtration rate (eGFR) reporting. We examined PCP and nephrologist CKD practices before and after routine eGFR reporting.</p> <p>Methods</p> <p>We conducted a retrospective cohort study of patients with CKD 3b-4 (eGFR < 45) seen at a university-based, outpatient primary care clinic. Using a chi-square or Fisher's exact test, we compared co-management rates, renal protective strategies, CKD documentation, and laboratory processes of care in 274 patients and 266 patients seen in a 6-month period prior to and following eGFR implementation, respectively.</p> <p>Results</p> <p>CKD co-management increased from 22.6% pre-eGFR to 48.5% post-eGFR (P < 0.0001). eGFR reporting did not improve angiotensin converting enzyme inhibitor or angiotensin receptor blocker use or quantitative urinary testing. However, non-steroidal anti-inflammatory drug avoidance (pre-eGFR 81.8% vs. post- eGFR 90.6%, P = 0.003) and phosphorus and parathyroid hormone testing improved (pre-eGFR vs. post-eGFR: 32.5% vs. 51.5%, P < 0.0001; 12.4% vs. 36.1%, P < 0.0001 respectively).</p> <p>Conclusions</p> <p>A marked increase in CKD co-management was observed following eGFR implementation. Although some improvements in processes of care were noted, this did not include angiotensin converting enzyme inhibitor or angiotensin receptor blocker use. Overall care remained suboptimal despite eGFR reporting; further strategies are needed to improve PCP and nephrologist CKD care.</p